Form ADV-44
Homeowners and Storm Victims Protection Act of 2011
Application for Reclassification
Single-Family Dwelling and Underlying Lot
Owner’s Name: _________________________________________________________
Mailing Address: __________________________________________________________
_________________________________________________________
_________________________________________________________
Homebuilders License Number: ___________________Expiration Date: _____________
Parcel ID: _________________________________________________________
Subdivision: __________________________________________________________
Date Construction Began: __________________________________________________
Documentary Evidence: (A copy of all documentary evidence must be submitted with this application)
Building Permit or Temporary Power Permit
On-site Sewage Disposal Permit Other _____________________
Certificate of Occupancy
Date Application Filed and Approved: _______________________________
Date Reclassification applied: October 1, ____________
For single-family dwellings and the fully-developed underlying lot the maximum reclassification period shall not
exceed a period of 24 months from the October 1 lien date following the date of application if application is
made prior to the October 1 lien date, unless terminated earlier. If application is made after the October 1 lien
date but on or before December 31, the maximum reclassification period shall begin on the October 1 lien date
preceding application.
I hereby affirm that to the best of my knowledge and belief this information including any accompanying
statements, permits, and other information is true and complete and I am eligible for the for the reclassification
requested herein.
______________________________________ ________________________
Signature Date
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